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SLEEP DEPRIVATION. Jeffrey Lin, M.D. Fellow, Sleep Medicine Stanford University Medical Center 5/6/2009. http://davidavery.files.wordpress.com/2008/04/sleep-deprived.jpg. OBJECTIVE. History of sleep deprivation studies Animal Studies Defining sleep deprivation

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sleep deprivation

SLEEP DEPRIVATION

Jeffrey Lin, M.D.

Fellow, Sleep Medicine

Stanford University Medical Center

5/6/2009

http://davidavery.files.wordpress.com/2008/04/sleep-deprived.jpg

objective
OBJECTIVE
  • History of sleep deprivation studies
  • Animal Studies
  • Defining sleep deprivation
  • Consequences of sleep deprivation
  • Treatment of sleep deprivation
  • Liabilities of sleep deprivation
  • Current studies regarding sleep deprivation
history of sleep deprivation
HISTORY OF SLEEP DEPRIVATION
  • 1894: Marie De Manaceine conducted the first documented animal studies
    • Kept puppies awake for 5 days
  • 1896: Patrick and Gilbert conducted the first human studies
    • 90 hour sleep deprivation
  • 1960: Dement conducted first partial sleep deprivation
    • REM sleep deprivation
  • 1964: Randy Gardner stayed awake for 264 hrs
  • 1989: Rechtschaffen performed sleep deprivation studies with mice using the disk-over-water method
disk over water method
DISK-OVER-WATER METHOD

http://web.bvu.edu/faculty/ferguson/Course_Material/polysomnographs/Sleep%20Deprivation%20Data/Apparatus.jpg

flower pot method
FLOWER POT METHOD

https:/.../attachments/34242959/flowerpot.jpg

animal studies
ANIMAL STUDIES
  • Scrawny appearance w/ disheveled fur.
  • Severe lesions on the tail and paws...no apparent cause was found
  • Increased food intake; consumption doubled during the latter phases of deprivation
  • Increased energy expenditure; doubled during the latter phases of deprivation
  • Decrease in body temperature, beginning about half way through the survival period
  • Weight loss; 18% - 20% drop in body weight.
  • Death; all experimental animals (but no control animals) died after 11-32 days of deprivation
  • No significant post-mortem differences in the brains or other major organs

Bergmann, Fang, Kushida, Everson, & Rechtschaffen, 1986

randy gardner
RANDY GARDNER

www.kk.org/quantifiedself/2007/10/eleven-days...

randy gardner1
RANDY GARDNER
  • Stayed awake for a high school science project
  • Had 2 of his friends keep him awake
  • Clinical condition monitored
    • Dr. William Dement
    • Lt. Cmdr. John Ross
timeline of events
TIMELINE OF EVENTS
  • Day 1 – Woke at 6 am and ready to go
  • Day 2 – Difficulty focusing eyes and signs of astereognosis
  • Day 3 – Moodiness, some sign of ataxia, inability to repeat tongue twisters
  • Day 4 – Irritability and uncooperative attitude, memory lapses and difficulty concentrating. First illusion/delusion

Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

timeline of events1
TIMELINE OF EVENTS
  • Day 5 – More hallucinations
  • Day 6 – Speech slowing and difficulty naming common objects
  • Day 7 – Irritability and speech slurring
  • Day 8 – Increased memory lapses
  • Day 9 – Episodes of fragmented thinking
  • Day 10 – Paranoia focused on a radio show. Able to beat Dr. Dement on pinball

Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

timeline of events2
TIMELINE OF EVENTS
  • Day 11 – Expressionless appearance, speech slurred and without intonation. Unable to perform serial 7’s past 65 because he forgot what he was doing.
  • Final day – Appeared in a press conference. “I wanted to prove that bad things didn’t happen if you went without sleep.”

Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

timeline of events3
TIMELINE OF EVENTS
  • Day 12 - Fell asleep for 14 hrs and 40 minutes
  • Stayed awake for 24 hrs, then slept a normal eight hours

Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

how much sleep
HOW MUCH SLEEP?
  • Quantity of sleep
    • How long a patient would sleep if left to awaken spontaneously
    • How alert the patient feels after different quantities of sleep
  • Quality of sleep
    • Appropriate distribution of sleep stages
  • Timing of sleep
    • Synchronization of process C and S

Pressman, Mark. Definition and consequences of sleep deprivation. UpToDate

quality of sleep
QUALITY OF SLEEP
  • Arousals can occur
    • Spontaneously
    • Secondary to sleep disorders
  • More frequent the arousal, more sleepiness during the day
    • Artificially disrupting sleep 60 times/hr X 2 days equals 40 – 60 hrs of total sleep deprivation
    • Sleep disturbance 5 times/hr can affect performance
    • Even acoustic tones that only caused EEG arousals increased daytime sleepiness

Bonnet, MH. Effect of sleep disruption on sleep performance and mood. Sleep 1985; 8:11

Martin, S, Wraith, PK, Deary, IJ, Douglas, NJ. The effect of nonvisible sleep fragmentation on daytime function. AJRCCM 1997; 155:1596

slective sleep deprivation
SLECTIVE SLEEP DEPRIVATION
  • Selective REM deprivation increases the propensity of a subject to enter REM sleep
    • Night 1 – 17 awakenings
    • Night 2 – 42 awakenings
    • Night 3 – 68 awakenings
  • Subjects required 5-7 times as many arousals to deprive them of SWS vs. REM

Agnew HW Jr et. Al. Percept Mot Skills 1967;24:851-8

how much sleep1
HOW MUCH SLEEP?
  • There is wide variation
  • American average 6 hrs and 40 min
    • Most desire 40 more min
  • Societal pressures are decreasing the average sleep time
  • Wehr: 8.5 hrs
  • Sleep < 4 hrs or > 10 hrs have increased mortality

Wehr, TA et. Al. Am J Physiol 1993; 265:R846-57

consequences of sleep deprivation
CONSEQUENCES OF SLEEP DEPRIVATION
  • Physical effects
    • Increased appetite
    • Temperature disregulation
    • Shakiness
    • Headaches
    • Increased pain sensitivity
    • Decreased in immune function

Ansch, Browman, Mitler, and Walsh. Sleep: A Scientific Perspective (1988)

impared immune function
IMPARED IMMUNE FUNCTION
  • 31 healthy males
  • Night 1 : uninterrupted sleep
  • Night 2 : awake until 3 am
  • Blood drawn every 30 min
  • Sleep monitored by EEG

Redwine L, et al. J Clin Endocrinol Metab 2000 Oct; 85(10):3597-603

variations in concentration
VARIATIONS IN CONCENTRATION

Redwine L, et al. J Clin Endocrinol Metab 2000 Oct; 85(10):3597-603

impared immune function1
IMPARED IMMUNE FUNCTION
  • IL-6 level rise was delayed in the PSD group
    • Elevated levels of IL-6 associated with Stages 1,2, and R
    • IL-6 levels during SWS similar to awake
  • Similar findings with GH release
  • Cortisol and melatonin levels did not show such shift

Redwine L, et al. J Clin Endocrinol Metab 2000 Oct; 85(10):3597-603

impared immune function2
IMPARED IMMUNE FUNCTION
  • 25 subjects, restricted to 6 hrs of sleep X 1 wk
  • IL-6 was increased in both sexes
  • TNF – alpha was increased in men
  • Peak cortisol secretion was lower
    • More pronounced in men

Vgontzas AN et. Al. J Clin Endocrinol Metab 2004 May;89(5):2119-26

impared immune function3
IMPARED IMMUNE FUNCTION
  • 42 healthy men
  • Two 2-hr naps daily Vs. total sleep deprivation X 4 days
  • Blood draws every 6 hrs
  • Compared to PSD subjects, TSD subjects had elevated TNF-alpha and IL-6 levels on day 4

Shearer WT, et al. J Allergy Clin Immunol 2001 Jan;107(1):165-70

psychological effects
PSYCHOLOGICAL EFFECTS
  • Irritability
  • Poor concentration
  • Aggression
  • Apathy
  • Time and place disorientation
  • Loss of emotional control
  • Paranoia
  • Sleepiness

Ansch, Browman, Mitler, and Walsh. Sleep: A Scientific Perspective (1988)

psychomotor changes
PSYCHOMOTOR CHANGES
  • Perceived exhaustion on endurance test
  • Decrements in speed and accuracy
    • Most obvious on long and monotonous tasks

Ansch, Browman, Mitler, and Walsh. Sleep: A Scientific Perspective (1988)

societal effects
SOCIETAL EFFECTS

www.personalfinanceanalyst.com/.../

societal effects1
SOCIETAL EFFECTS
  • 24 – hour society
  • Car accidents : 90,000 per year
  • American Airlines 1420 crash
  • Chernobyl disaster
  • Exxon Valdez grounding
  • Shift work
  • On-Call duties
maggie s law
MAGGIE’S LAW
  • July 20, 1997: Maggie McDonnell was killed in a head-on collision in Clementon, NJ
    • The driver of the van had been awake for 30 hrs and smoked crack cocaine before the crash
  • He was acquitted because the lawyer argued that falling asleep was not a crime
  • August 2003: Maggie’s law passed in NJ
    • If a fatal accident was caused by a driver who stayed awake > 24 hrs, they can be charged with vehicular homicide, up to 10 years in prison, and $100,000 fine
  • August 2005: Man was sentenced to 5 yrs in state prison for killing another driver after being sleep deprived for > 24 hrs

Death by auto o vessell. N.J.S.2C.11-5, pub. L. 2003 c. 143. August 5, 2003

commercial drivers
COMMERCIAL DRIVERS
  • August 2005: US Federal Motor Carrier Safety regulations
    • Drivers may only drive for 11 hrs in any one day
    • Must have 10 hrs free from duty the day before work
    • Workday can not be longer than 14 hrs
    • Restriction on the total number of hrs worked in a week
  • Prevalence of drivers sleeping < 5 hrs: 13.5%

Federal Motor Carrier Safety Administration. HOS regulations. 2005

slide35

9 + 4.4 minutes

4.8 + 4.1 minutes

Reddy, R. et al. Chest 2009; 135:81-85

housestaff vs faculty
HOUSESTAFF VS. FACULTY

Marcus CL, Loughlin GM. Sleep 1996; 19:763-766

housestaff vs faculty1
HOUSESTAFF VS. FACULTY

Marcus CL, Loughlin GM. Sleep 1996; 19:763-766

treatment for sleep deprivation
TREATMENT FOR SLEEP DEPRIVATION

www.flickr.com/photos/doncolleen/1528345670/

treatment for sleep deprivation1
TREATMENT FOR SLEEP DEPRIVATION
  • Limiting time on task
  • Physical fitness
  • Exercise
  • Rest breaks (5-20 min)
  • Napping
  • SLEEP

Kushida, CA. Sleep Deprivation: Basic Science, Physiology, and Behavior. 2005. Marcel Dekker

treatment for sleep deprivation2
TREATMENT FOR SLEEP DEPRIVATION
  • Recovery sleep
    • Sleep onset latency shorter
    • Arousal threshold increased
    • Increased in SWS first, followed by REM
    • Increased sleep time
      • For 1 night of TSD, sleep time may increase 2-4 hrs
      • Obligatory sleep vs. Facultative sleep

Kushida, CA. Sleep Deprivation: Basic Science, Physiology, and Behavior. 2005. Marcel Dekker

slective sleep deprivation1
SLECTIVE SLEEP DEPRIVATION
  • Recovery sleep from selective SWS deprivation same as total sleep deprivation
    • SWS increased on night 1
    • REM increased on nights 2 and 3
  • Recovery sleep from selective REM sleep deprivation different
    • SWS does not increase
    • REM increased on all 3 nights

Agnew HW Jr et. Al. Percept Mot Skills 1967;24:851-8

pharmacologic treatment
PHARMACOLOGIC TREATMENT

http://www.usdoj.gov/dea/pubs/abuse/5-stim.htm

pharmacologic treatment1
PHARMACOLOGIC TREATMENT

Kushida, CA. Sleep Deprivation: Basic Science, Physiology, and Behavior. 2005. Marcel Dekker

liabilities of sleep deprivation
LIABILITIES OF SLEEP DEPRIVATION

www.westsofeastdean.co.uk/large_gavel.html

liabilities of sleep deprivation1
LIABILITIES OF SLEEP DEPRIVATION
  • Error of omission – Individual fails to respond quickly to a situation
  • Error of commission – Individual creates unnecessary risk of harm
  • Drivers are liable for consequences of falling asleep if they were aware of the risks associated with their sleep disturbance and did not take measures to reduce those risks

People V. Schaffer. 364 N.E. 2d 109 (III App. 1977)

driver liability
DRIVER LIABILITY
  • Evidence of a person sleeping while driving = Negligence
    • Drivers bear the burden of rebutting the presumption of negligence
  • Recklessness
    • Sufficient rest preceding the crash
    • Time driving prior to crash
    • Prior warning that sleep was impending
  • Recklessness = Monetary judgment
employer liability
EMPLOYER LIABILITY
  • May be liable to an employee or third party if the accident occurred within the scope of employment
  • Employee fell asleep while driving a company truck home, causing a serious crash and injuring others
    • Employer was liable because the employee had a load of tires to deliver on the way home
  • On-call employee was driving back to work in a company vehicle and fell asleep, causing injuries to others
    • Employer was not liable because the employee was on a personal errand

Mayes vs. Goodyear Tire & Rubber Co., 144 S.W. 3d 50 (Tex. App. 2004)

J&C Drilling Co. Vs. Salaiz, 866 S.W. 2d 632 (Tex. App. 1993)

clinician liability
CLINICIAN LIABILITY
  • Diagnostic evaluation is warranted when a sleep disorder is suspected
  • All patients who have sleep disorders should be warned about risk of operating a motor vehicle or dangerous machinery while sleepy
    • For the high-risk population, they should be advised not to drive until therapy has been instituted and proven effective
  • Clinicians are liable if they fail to inform the patient regarding risks of medical condition/treatment
  • Clinicians are not responsible for the actions of patients who fail to take measures to reduce their risk, although the risk of liability may be higher if they are required by state statute to report a driver to the DMV

Joy vs. Eastern Maine Medical Center, 529 A.2d 1364 (Me. 1987)

current studies in sleep deprivation
CURRENT STUDIES IN SLEEP DEPRIVATION
  • “Distinct effects of acute and chronic sleep loss on DNA damage in rats.”
  • Sleep deprivation of rats
    • 24 hrs
    • 96 hrs
    • 21 days
  • Evaluate DNA damage in blood, brain, liver, and heart cells

Andersen ML, Ribeiro DA, et. Al. Prog Neurophychopharmacol Biol Psychiatry. 2009 Feb 28.

single cell gel comet assay
SINGLE CELL GEL (COMET) ASSAY
  • Damaged DNA have more broken strands
  • Travels further toward the anode
  • The longer the comet tail, the more DNA damage is present

Andersen ML, Ribeiro DA, et. Al. Prog Neurophychopharmacol Biol Psychiatry. 2009 Feb 28.

dna damage in brain cells
DNA DAMAGE IN BRAIN CELLS

Andersen ML, Ribeiro DA, et. Al. Prog Neurophychopharmacol Biol Psychiatry. 2009 Feb 28.

sleep deprivation and athletes
SLEEP DEPRIVATION AND ATHLETES
  • “Effects of sleep deprivation on cardiorespiratory functions of the runners and volleyball players during rest and exercise.”
  • Spirometric at rest and incremental exercise on ergometer
    • Following one night of sleep
    • One night of sleep deprivation (25-30 hrs)

Azboy O, Kaygisiz Z. Acta Physiol Hung. 2009 Mar;96(1):29-36

sleep deprivation and athletes rest
SLEEP DEPRIVATION AND ATHLETES - REST

Azboy O, Kaygisiz Z. Acta Physiol Hung. 2009 Mar;96(1):29-36

sleep deprivation and athletes exercise
SLEEP DEPRIVATION AND ATHLETES - EXERCISE

Azboy O, Kaygisiz Z. Acta Physiol Hung. 2009 Mar;96(1):29-36

short naps and athletic performance
SHORT NAPS AND ATHLETIC PERFORMANCE
  • “The role of a short post-lunch nap in improving cognitive, motor, and sprint performance in participants with partial sleep deprivation.”
  • 10 healthy males with partial sleep deprivation (23:00 to 3:00)
  • Between 13:00 to 13:30
    • Napped
    • Sat quietly
  • Assess alertness, short-term memory, intra-aural temperature, heart rate, choice reaction time, grip strength, 2m and 20m sprint

Waterhouse J, Atkinson G, Edwards B, ReillyT. J Sports. Sci. 2007 Dec;25(14):1557-66

performance factors
PERFORMANCE FACTORS

Waterhouse J, Atkinson G, Edwards B, ReillyT. J Sports. Sci. 2007 Dec;25(14):1557-66

take home points
TAKE HOME POINTS
  • Sleep is important
    • Total sleep time
    • Sleep quality
    • Timing of sleep
  • Sleep deprivation can result in adverse outcomes
    • Physical consequences
    • Psychiatric consequences
    • Economic consequences
    • Societal consequences
  • Treatment is effective
    • Proper amount time allotted for sleep
    • Well-timed naps
    • Medications to help regulate sleep vs. stay awake
thanks
THANKS!

www.azfotos.com/people/children/boy-pictures.htm

www.firstpeople.us/pictures/bear/Sleeping-Bea...

www.all-creatures.org/ak/photo-sleepkitty.html

colintellsyouwheretogo.blog.co.uk/page/2/

animal studies1
ANIMAL STUDIES
  • Heat seeking behavior
  • Increased food intake
  • Weight loss
  • Increased metabolic rate
  • Increased plasma norepinephrine
  • Decreased plasma thyroxine
  • Increased T3/T4 ratio

Rechtschaffen, A, and Bergmann, B. Behavioural Brain Research 69 (1995) 55-63